Lactated Ringer’s (LR) Solution in Anesthesia: Key Considerations for Safe Use

Introduction

Lactated Ringer’s (LR) solution is one of the most commonly used balanced crystalloids for fluid resuscitation, particularly in critical care settings such as sepsis, trauma, and major surgeries. It provides not only water and electrolytes but also lactate, which serves as a bicarbonate precursor to help correct acidosis. While LR is largely considered safe and effective, there are specific clinical scenarios where its administration may lead to elevated lactate levels, raising concerns for certain patient populations. This article discusses these considerations and guides anesthesiologists on the safe use of LR, based on current literature.

1. Severe Liver Dysfunction

One of the key mechanisms by which lactate is metabolized is through the liver. In patients with significant hepatic impairment, such as those with cirrhosis or liver failure, the liver’s ability to clear lactate is reduced. This can lead to an increase in serum lactate levels when LR is administered, although this increase rarely results in clinically significant lactic acidosis. The accumulation of lactate in such patients necessitates cautious use of LR, particularly during surgeries involving the liver, as the risk of lactate elevation is heightened.

Reference:

• Kellum JA. Lactate metabolism and the liver: Is lactic acidosis a good thing? Crit Care Med. 2000;28(1):258-259.

2. Large Volume Resuscitation

During major surgeries or trauma cases requiring rapid large-volume resuscitation, LR is often administered in significant amounts. While lactate levels may transiently increase, this is not typically associated with acidosis, especially in patients with intact liver function. Anesthesiologists should still be vigilant for potential electrolyte imbalances or fluid overload in patients receiving high volumes of LR. The hyperchloremic acidosis associated with normal saline, often used in similar situations, makes LR the preferable fluid, as it avoids this complication.

Reference:

• Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839.

3. Patients with Cirrhosis

In cirrhotic patients, the metabolic capacity of the liver is compromised, which may lead to an accumulation of lactate following the administration of LR. Several studies have highlighted that these patients are more likely to experience elevated lactate levels due to their reduced ability to metabolize lactate. For these patients, close monitoring of lactate levels is recommended, and the use of alternative fluids like PlasmaLyte may be considered if concerns over lactate metabolism arise.

Reference:

• Weinberg L, Collins N, Van Mourik K, et al. The pathophysiology of lactate in critical illness: A review of evolving concepts. Crit Care Resusc. 2016;18(3):279-287.

4. Hepatic Hypoperfusion

Significant reductions in hepatic blood flow, commonly seen in cases of severe shock or during major surgeries such as hepatic resections, impair the liver’s ability to clear lactate. In these situations, the use of LR may exacerbate lactate elevation. Anesthesiologists should weigh the benefits of LR’s buffering capacity against the risk of lactate accumulation, especially in patients undergoing procedures that involve prolonged periods of hypoperfusion.

Reference:

• Harrison SM, Bates AT, Martin DS. Perioperative fluid therapy in major hepatic surgery. BJA Educ. 2016;16(7):246-251.

5. Massive Transfusion Protocols

In trauma or major surgery requiring massive transfusions, the administration of large amounts of LR can theoretically contribute to elevated lactate levels. However, in the context of such resuscitation scenarios, any increase in lactate due to LR is likely overshadowed by the metabolic derangements associated with trauma or hemorrhagic shock. As such, LR remains a viable fluid choice in massive transfusion protocols, though careful monitoring of lactate levels is still recommended.

Reference:

• Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572.

6. Renal Dysfunction

While the kidney plays a lesser role in lactate metabolism compared to the liver, patients with renal impairment may exhibit slight increases in lactate when given LR. The clinical significance of this is usually minimal, but in severe renal dysfunction, such as end-stage renal disease, careful consideration should be given to fluid choices and monitoring.

Reference:

• Morgan TJ. The ideal crystalloid – what is ‘balanced’? Curr Opin Crit Care. 2013;19(4):299-307.

7. Septic Patients with Elevated Baseline Lactate

In septic patients with already elevated lactate levels, LR administration may transiently increase serum lactate further. However, this increase is typically not clinically significant, and LR’s benefits in maintaining electrolyte balance and acid-base status outweigh this risk. As a result, LR remains a preferred fluid for resuscitation in sepsis, especially when compared to saline, which can worsen metabolic acidosis.

Reference:

• Raghunathan K, Shaw AD, Bagshaw SM. Lactated Ringer’s solution in sepsis: rationale for the solution and the disease. Clin Exp Emerg Med. 2016;3(4):229-234.

Conclusion

While Ringer’s Lactate is a highly effective resuscitation fluid for a variety of critical conditions, including sepsis, there are certain situations where its use requires caution due to the potential for elevated lactate levels. These situations, though relatively uncommon, highlight the need for anesthesiologists to individualize fluid management based on the patient’s liver function, the volume of fluid required, and the overall clinical context. In most cases, the benefits of LR outweigh the risks, particularly in comparison to alternative solutions like normal saline, which carry their own set of complications.

References:

1. Kellum JA. Lactate metabolism and the liver: Is lactic acidosis a good thing? Crit Care Med. 2000;28(1):258-259.
2. Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839.
3. Weinberg L, Collins N, Van Mourik K, et al. The pathophysiology of lactate in critical illness: A review of evolving concepts. Crit Care Resusc. 2016;18(3):279-287.
4. Harrison SM, Bates AT, Martin DS. Perioperative fluid therapy in major hepatic surgery. BJA Educ. 2016;16(7):246-251.
5. Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572.
6. Raghunathan K, Shaw AD, Bagshaw SM. Lactated Ringer’s solution in sepsis: rationale for the solution and the disease. Clin Exp Emerg Med. 2016;3(4):229-234.